topical treatment with antibiotics · comments no major side-effects noted; occasional fainting,...
TRANSCRIPT
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TOPICAL TREATMENT WITH
ANTIBIOTICS EXPERIENCE AT ALLADA
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PLANREMINDER OF THE AIMS OF TREATMENT WITH ANTIBIOTICSMETHOD USED FOR DOCUMENTATIONSUMMARY OF ACTIVITIES CARRIED OUT AT ALLADASUCCESSESFAILURESDIFFICULTIESPROSPECTS
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AIMS OF TREATMENT WITH ANTIBIOTICS
CATEGORY 1: To cure lesions without the need for surgery or to reduce surgery to a minimumCATEGORY 2:To reduce the scale of the surgical operation
CATEGORY 3:To control the M. ulcerans infection before the operation
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DOCUMENTATIONADMISSION
MEASUREMENT+ SWAB + PHOTOGRAPHY
W2MEASUREMENT + PHOTOGRAPHY
W4BIOPSY + PHOTOGRAPHY
W6PHOTOGRAPHY
NB: from W4 onwards, several situations are presented: Satisfactory evolution continue with ATB without surgery and with documentation as in W2Ambivalent, unsatisfactory or stationary evolution, Surgery measurement hard to interpret documentation as in W6
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69 (78%)
4 (67%)
45 (73%)
20 (95%)
Complied with protocol
20 (22%)
2 (33%)
17 (27%)
1 (5%)
Operated at w0
89
6
62
21
Number of patients
Total
Cat 3
Cat 2
Cat 1
MONTH
CDTUB ALLADA
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52 (75%)
4 (100%)
35 (78%)
13 (65%)
Operated at W4
69
4
45
20
Complied with
protocol
17 (25%)Total
0 (0%)Cat 3
10 (22%)Cat 2
7 (35%)Cat 1
Scarred without surgery
MONTH
CDTUB ALLADA
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Total
Cat 3
Cat 2
Cat 1
MONTH
22 (42%)
2 (33%)
11 (31%)
9 (69%)
DEBRIDEMENT + IMMEDIATE GRAFT
SURGICAL PROCEDURENumber of patients
operated at W4
3 (6%)
1 (33%)
2 (6%)
0 (0%)
GRAFT ALONE
27 (52%)
1 (33%)
22 (63%)
4 (31%)
EXCISION
524
3513
CDTUB ALLADA
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CDTUB ALLADA
Duration of hospital stayMedian = 71 days
Period taken for scar to form after excision:Median = 32 days
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CONCLUSIONS
CATEGORY 1: Cure the lesions without the need for surgery (35%) or with minimum surgery (69%)
CATEGORY 2:Reduce the scale of the surgical operation
(10+11+2)/45 = 51%
CATEGORIE 3:Control the M. ulcerans infection before surgery: RESULT TO BE DISCUSSED
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SUCCESSES
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FabriceInitial photograph (23/02/05)OEDEMA, ULCER AND MAJOR UNDERMINING
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Fabrice
4TH week: 21/03/05OEDEMA HAS DISAPPEAREDSCARRING HAS BEGUN (FORMATION OF EPIDERMAL TISSUE AROUND THE EDGE)
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Fabrice
6th week: 04/04/05NORMAL SKINSCARRING OF LESION ALMOST COMPLETE
8th week : 18/04/05SCARRED
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DelphinAdmitted: 21/02/05MEASUREMENT:12/3
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Delphin
2nd week: 07/03/05MESUREMENT: 11/3
4th week : 28/03/05MEASUREMENT: 9/4
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Delphin
6th week: 04/04/05MEASUREMENT:7/0,5
8th week: 18/04/05SCARRED
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ONSET:04/03/05MEASUREMENT:5/3
MICHELINE
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MICHELINE
W2: 18/03/05MEASUREMENT :5/3
W4: 30/03/05 MEASUREMENT : 4/2
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W6: 14/04/05MEASUREMENT:4/2PLASTIC SURGERY OF EYELID
W8: 28/04/05SCARRING WITH DISCRETE
DROOPING OF EYELID
MICHELINE
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ONSET:10/03/05MESUREMENT:4,5/3
ALPHONSE
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ALPHONSE
W2: 24/03/05MEASUREMENT :4,5/3
W8: 04/05/05MEASUREMENT:3,5/1,5
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DONALDAge 12 yearsSex: maleDate of admission24/02/2005Type of lesion ulcerSite: LLL+RULInitial measurement16/12, 11/8.5cmCat 3 (Dissemination)
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ATB stopped at W8. Dressing continued04/07/05: Scarring under way
DONALD
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12/09/05Scarring without surgery
DONALD
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02/10/05
Follow-up 8 months later
DONALD
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MARCELLINEAge 6 yearsSex: femaleDate of admission24/02/2005Type of lesion ulcerSites: Dis.Initial measurement19/14cm et 16/12 cmCat 3
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04/07/05Scarring has begun
MARCELLINE
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MARCELLINE02/10/05
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SERALIEAge 10 yearsSex: maleDate of admission01/06/2005Type of lesionULCERATIVE PLAQUESite: AbdomenInitial measurement13/7cmCat 2
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SERALIE29/06/05
Measurement W4: 11/3
25/08/05Scarring at W8 + 1 week
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ELIEAge 12 yearsSex: maleDate of admission24/02/2005Type of lesion ulcerSite: AbdomenInitial measurement 16/8cmCat 2
04 07 05Scarring without surgery
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FAILURES ???
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MARIETTE34 years old1st admitted to hospital on 16/11/04Origin: Ze centrePeriod before consultation: 1 yearInitial lesions:
large ulcer of the left hemithorax Osteomyelitis of the carpal bones
AFB ++ (23/11/04) Culture (-)
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MARIETTETreatment immediately on admission:
Excision + graft of the thoracic lesionCurettage of the bones of the carpal lesionABT
EvolutionSatisfactory, with good, rapid scarringDischarged on 12/02/05
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MARIETTEReadmission on 11/04/05 for a plaque on the right knee with incipient ulcerationAFB (-) CULTURE (-)Adoption of a new 8-week course of antibiotic treatment, with limited excision in W1 (15/04/05)
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MARIETTERapid scarring, however, a new contiguous lesion appeared on 20/05/05; currently under AB treatment;Extensive complementary excision performed on 30/05/05; continuation of AB treatment until completion
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MARIETTEFavourable evolution with controlled scarring (graft)Discharged on 29/08/05
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ROBERT
Age : 38 years Sex : MAddress : ToffoDate of admission: 12/12/04Period before consultation: 6 monthsInitial lesion :
Ulcer on upper 1/3 of left leg
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ROBERT
Treatment on admissionExcisionGraftABT ( 19/01/05 to 21/03/05)
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Evolution
Scarring of initial lesion: 29/04/05However, readmitted on 23/05/05 for a new lesion on his left heel. Further course of ABT, followed by excision-graft at W2
ROBERT
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ROBERT
Stationary evolution with delayed scarring, requiring an x-ray of the heel. Detection of a geode in the heel bone: procedure followed:
Curettage of bone : 30/08/05
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ROBERT
Evolution (30/08/05):
Favourable. Scarring and discharge on 15/11/05
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JONAS08/09/05AGE:4yearsSEX:MALECAT 2SITE: RLLINITIAL MEASUREMENT: 9/5AFB +ABT
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JONAS
W2: 21/09/05Measurement :9/5Evolution: stationary
W6:17/10/05Evolution: stationaryNodule on the thigh
excision of both lesionsAFB +
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JONAS
22/11/05 (W2 AFTER END OF ABT)
NEW PLAQUE IN THE POSTERIOR KNEE HOLLOW ON THE SAME LIMBMEASUREMENT:10/7
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JONAS
22/11/05PLAQUE
EXCISION + IMMEDIATE SUTUREAFB (-)
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JONAS
02/12/05 (W4 AFTER END OF ABT)
NODULE AT THE THIGH ROOT ON THE SAME LEGEXCISION; AFB (-)
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JONAS
21/12/05LESIONS ALMOST COMPLETELY SCARREDPINCH GRAFT
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COMMENTSSatisfactory evolution of ulcerative and non-ulcerative oedemas with considerable "reduction" limitation of the area to be excisedPlaques always develop into ulcers; persistence of dystrophic granular tissue which has to be excisedFor the most part, cases of recurrence during or after RW were attributable to failure to comply with the protocol (operation before W4); in addition, AFB and culture negative
ARE THESE MERELY INFLAMMATORY REACTIONS ATTRIBUTABLE TO RESIDUAL TOXINS?WHAT IS THE CORRECT PROCEDURE IN THESE CASES?
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COMMENTSNo major side-effects noted; occasional fainting, buzzing in the ears and hearing lossLonger hospital stayDecentralized case management is possible and accepted by the population fosters early case detection, integration of the peripheral health system into BU case management, lightens the burden on CDTUBWith the exception of a number of recurrences reported during treatment or immediately after discharge, none of the patients treated in 2004 at W/R has been admitted with recurrence.
However, active case detection is required in this respect.
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DIFFICULTIESStaff have some initial difficulties adjusting Case confirmation and laboratory follow-up:
What type of documentation is needed for non-ulcerative lesions?
Should we perform punch biopsy immediately on admission or after W1?
Is there a risk of iatrogenic dissemination????Should we wait until W4 to perform biopsy during excision?
Is there a risk of increasing the likelihood of negative results???
Ulcerative lesions: How far are results of swab and biopsy comparable? (SENSITIVITY? PPV? NPV?)
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PROSPECTSIntroduction of decentralized administration at Allada
Prerequisites:Feasibility studySelection of eligible centres
Assessment of importance of ototoxic effects Goal: to determine whether or not systematic monitoring of patients' hearing is necessary?
Study of the acceptability of this treatment for the target groups.